Figure 1
Study selection.
Table 1
Characteristics of included studies (ordered chronologically).
| Study ID | Country and region | Programme duration | Description of the intervention | Study outcome(s) measured | Level(s) of prevention or care | Programme scale: numbers of healthcare workers and patients involved | ||
|---|---|---|---|---|---|---|---|---|
| 1° | 2° | 3° | ||||||
| Iyengar 1991 [21] | India: Haryana State, Ambala district. | 2 years | An ARF/RHD health education and training programme for health workers, teachers, and school pupils, as well as the registration of new cases and prescription of penicillin. | I. The number and source of: suspected case referrals, registered cases, and confirmed cases of RF and RHD (case detection rate) II. Adherence to secondary prophylaxis. | ✓ | 202 healthcare workers and 773 teachers were trained to recognise the signs and symptoms of ARF and RHD. Of the 254 suspected case referrals, 77 were registered in health centres, of which 61 were confirmed and began secondary prophylaxis. | ||
| WHO 1992 [23] | 16 countries participated: (Africa) Mali, Zambia, Zimbabwe; (Americas) Bolivia, El Salvador, Jamaica; (Eastern Mediterranean) Egypt, Iraq, Pakistan and Sudan; (South-East Asia) India, Sri Lanka and Thailand; (Western pacific) China, the Philippines, and Tonga. | 4 years | Personnel training, health education and a central ARF/RHD register. | I. Secondary prophylaxis coverage. II. ARF reoccurrence. | ✓ | Across all of the countries, 24 398 personnel trained; 33 651 patients were registered. | ||
| Nordet 2008 [22] | Cuba: Pinar del Rio. | 10 years | A community based prevention and treatment of ARF/RHD through healthcare education and training of health personnel as well as the establishment of dedicated register centres. | I. The incidence of ARF (new and recurrent cases). II. The prevalence and severity of RHD. III. Secondary prophylaxis compliance. IV. The proportion of patients requiring hospitalization. | ✓ | ✓ | All 5–25 year old permanent residents of the province during the study period were included (n = 273 933). | |
| Ralph 2013 [24] | Australia: Northern Territory. | 3 years | A continuous quality improvement (CQI) strategy to improve the documentation and care of ARF/RHD patients. | I. Proportion of patients receiving scheduled BPG. II. Proportion of patients reviewed by their doctor in the past two years. III. The quality of data recorded on ARF/RHD patients: ARF episodes and RHD risk category information. | ✓ | 6 health centres participated; 154 ARF/RHD patients. | ||
| Kwan 2013 [25] | Rwanda: Kirehe and Southern Kayonza districts. | 4.4 years | Outpatient heart failure services implemented at pre-existing integrated NCD clinics at two rural hospitals. Portable ECG and algorithms were used for the diagnosis and management of patients with suspected heart failure. | I. Distribution of conditions (including RHD) among heart failure patients. II. Programme retention. III. Mortality among patients with confirmed diagnoses. | ✓ | Each clinic team included 2 nurses and 2 administrative personnel, supervised by generalist physicians. Out of 237 patients suspected of heart failure, 192 had a confirmed cardiologist diagnosis and were enrolled in the heart failure programme. | ||
[i] ARF, acute rheumatic fever; RHD, rheumatic heart disease.
Figure 2
The extent and nature of integration by level of prevention for rheumatic heart disease programmes in various countries.
Table 2
Programme performance.
| Country (Study ID) | Outputs | Outcomes | Impact |
|---|---|---|---|
| Primary prevention | |||
| Cuba (Nordet 2008) [22] | ▪ Increased medical awareness among young patients. | ▪ Timely diagnosis and treatment of strep-throats. | ▪ The incidence of first ARF attacks declined from 12.2 per 100 000 in 1986 to 2.1 per 100 000 in 1996. |
| Secondary prevention | |||
| Australia (Ralph 2013) [24] | ▪ The number of clinical records audited each year were 154 in 2008, 145 in 2009, and 156 in 2010. |
| ▪ Not reported |
| Cuba (Nordet 2008) [22] | ▪ 327 patients registered over the study period. | ▪ Increased regular secondary prophylaxis compliance of registered patents (from 50% in 1986 to 93.8% in 1996). ▪ 86.1% decline in the cost of managing the disease. | ▪ Decline in the prevalence of ARF and RHD (8.0 to 2.0 cases per 1 000 school children). ▪ Decline in the incidence of recurrent attacks of ARF (6.4 to 0.4 per 100 000). ▪ Decreased severity of RHD (5 cases of severe RHD in 1986 to only 1 in 1996). ▪ Decrease in the number and of patients requiring hospitalization after the acute attack (from 41.1% of the 134 registered cases during 1986-90 to 8.3% of the 193 registered cases during 1991–96). |
| India (Iyengar 1991)[21] | ▪ A total of 254 suspected cases of ARF or RHD referred by teachers, health workers, and medical officers. | ▪ 3.5 time increases in the case detection rate in the intervention block (7.8/100 000/year to 27.5/100 000/year). ▪ 95% compliance to secondary prophylaxis in the first 6 months, this declined to 85% after 2 years. | ▪ Not reported. |
| ▪ The diagnosis and registration of 77 new cases of ARF/RHD (of which 61 were subsequently confirmed to have the disease). | |||
| Multiple countries (WHO 1992) [23] | ▪ 33 651 total patients identified and registered. ▪ 95.7% of patients received BPG injections, 2.1% oral penicillin, 0.1% sulfadiazine, and 2.1% erythromycin. ▪ 36 patients had an adverse reaction to BPG (0.3% patient-years), of whom 4 died. | ▪ The rate of average prophylaxis coverage was 70%. ▪ The rate of coverage per 100 patients registered per month averaged 63.2% (range, 23.8–96.9%). ▪ Reoccurrence of ARF occurred in 53 patients (0.4% patient-years), of whom only 2 were receiving regular BPG. | ▪ Although it is stated that the reoccurrence rate of ARF decreased, no evidence was presented. |
| Tertiary care | |||
| Rwanda (Kwan 2013) [25] | ▪ 192 patients were confirmed to have heart failure and were enrolled at the clinic. Of this cohort, 61 patients (32%) had RHD (26 patients were below the age of 18 years and 35 patients were adults). ▪ Over the course of 4.4 years, the mean time spent in care was 19 months. The median time in care for alive patients with complete records (n = 169) was 13 months for children and 20 months for adults. | ▪ The observed retention in the programme was 62%. Fifty-five patients (29%) were lost to follow-up. ▪ 18 patients (9%) died, of which 3 had RHD. Mortality might be underestimated due to those lost to follow-up. | ▪ Not reported. |
Figure 3A
The effect of partially integrated ARF/RHD programmes on ARF/RHD-related outcomes.
Figure 3B
The effect of an integrated programme on ARF secondary prophylaxis compliance.